Vulva ca sep course quick revision 2012

Vulva ca sep course quick revision 2012

  1. Tariq Mohammed
    Vulva ca sep course quick revision 2012
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    Vulva ca sep course quick revision 2012
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    • 1. Vulvar Cancer with special guest VIN Professor Khalid Sait (FRCSC) Chairman of Scientific chair of Prof. Basalamah for gynecological cancer Director of Gynecology oncology unit Faculty of medicine King Abdulaziz university Jeddah, Saudi Arabia
    • 2. Epidemiology  4% of gential tract malignancies  Mean age 65 is decreasing  Two types: VIN associated Vulvar dystrophy Prevalence 20-30% 50-60% Age Younger 30-35 Older 55-85 Histology Poorly diff./ non-keratinizing Well diff./ keratinizing Lesions Multifocal Unifocal
    • 3. Epidemiology  4% of gential tract malignancies  Mean age 65 is decreasing  Two types: VIN associated Vulvar dystrophy Prevalence 20-30% 50-60% Age Younger 30-35 Older 55-85 Histology Poorly diff./ non-keratinizing Well diff./ keratinizing Lesions Multifocal Unifocal
    • 4. Epidemiology  4% of gential tract malignancies  Mean age 65 is decreasing  Two types: VIN associated Vulvar dystrophy Prevalence 20-30% 50-60% Age Younger 30-35 Older 55-85 Histology Poorly diff./ non-keratinizing Well diff./ keratinizing Lesions Multifocal Unifocal
    • 5. Risk Factors  Smoking  Vulvar dystrophy  VIN  HPV 16 and 18  Immunodeficiency  Previous cervical cancer  Northern European  Radiation
    • 6. Presentation  Symptomatic  Pruritis  Soreness  Dysparunia  Lumps  Asymptomatic 20%
    • 7. Presentation  Associations  CIN  PAIN in up to 30% of cases
    • 8. Diagnosis  Vulvoscopy  Enhances examination  Useful in selecting sites for biopsy  Acetic acid  Can enhance lesions  Makes clinically unimportant HPV obvious  Toludine blue  Not used clinically
    • 9. Diagnosis: Biopsy  Use local anaesthetic  Xylocaine  EMLA cream  Punch biopsy  Keyes punch  Cervical biopsy forcep  Haemostasis  Apply AGNO3  Apply monsels soln  suture
    • 10. 10 Marcaine 0.5 % w/o
    • 11. Classification: 1989  Intraepithelial neoplasia  Squamous  VIN 1  VIN 2  VIN 3  Nonsquamous intraepithelial neoplasia  Paget’s disease  Tumours of the melanocytes, non invasive (melanoma in situ) ISSVD Int J Gynecol Pathol 1989;8:83 VIN 3 replaces, Bowens disease, Erythroplasia of Queyrat,Carcinoma in situ ,Bowenoid papulosis
    • 12. VIN White plaques Pigmented: brown/ red Condyloma
    • 13. ISVVD 2004  VIN 1  VIN 2, 3 = VIN  VIN  Usual type VIN ( warty, basaloid) HPV associated (type 16 in > 80%)  Differentiated type VIN 30 yrs Treated VIN Natural History Spontaneous regression Can occur Women < 30 yrs Risk of subsequent malignancy 2.5-7% Risk of invasion at treatment 18-22%
    • 18. Preinvasive neoplasia - VIN “Early and effective treatment, elimination of smoking and long-term follow-up of all patients with VIN is imperative.” Local excision: local 0.5cm margin, epidermis and dermis Skinning vulvectomy: multifocal, epidermis only Laser ablation: multifocal 1-3mm depth 5FU: multifocal Imiquimod: Only AFTER appropriate biopsies to rule out invasive disease
    • 19. •Surface epithelium • only possible with laser • Epidermis & papillary dermis • Condylomata • Epidermis & part of reticular dermis • VIN • To fascia • Malignancy Principles of excision 4th plane
    • 20. Surgery: Wide local excision  Commonest surgical modality  Excise skin with 5mm margins
    • 21. Surgery: Wide local excision  Free margins  90% success rate  Involved margins  50% success rate
    • 22. Surgery: Skinning vulvectomy  Introduced 1968  Rutledge and Sinclair  Extensive often multifocal lesions  Especially in hair bearing areas  Removal of large area of vulva skin  5 mm margins  Shallow layer of skin removed  Split thickness skin graft used to fill defect
    • 23. Surgery: Skinning vulvectomy  Problems  Extensive surgery  Sexual dysfunction post op  Recurrence  Up to 39 %  Can occur in grafted areas  Does provide a pathological specimen when invasion is a concern  Can be used in association with laser
    • 24. Vulva-Laser  Usually use “superpulse”  Less thermal damage  Less carbonization than lowering the energy and using a continuous waveform
    • 25. 26 LASER Therapy 8 Weeks Post Laser
    • 26. Other Treatments  Photodynamic therapy  using topically applied 5-aminolevulinic acid.  Limited experience and availability  Labour intensive  5FU (Efudex cream)  Painful –not recommended  Imiquimod cream 5% (Aldara)  promising  5% cream applied 3X a week for 8 weeks or more, continue 2 weeks after disappearance 27
    • 27. Preinvasive neoplasia - VIN 30% of women will have recurrence Especially: - high grade - multifocal - positive margins Therefore long-term follow up is necessary
    • 28. Paget’s Vulva  Often multifocal erethematous-whithe plaques  2 cm in size or with stromal invasion > 1.0 mm, confined to the vulva or perineum with negative node FIGO 2010 staging of vulvar cancers
    • 36.  Stage II: Tumor of any size with extension to adjacent perineal structures (1/3 lower urethra, 1/3 lower vagina and/or extension to the anus) with negative nodes.
    • 37. Stage III: tumor of any size with or without extension to the adjacent perineal structures (1/3 lower urethra, 1/3 lower vagina, anus) with positive inguino-femoral lymph nodes.  IIIA: (i) 1 lymph node metastasis ≥ 5 mm (ii) 1–2 lymph node metastasis(es) < 5 mm  IIIB: (i) 2 or more lymph node metastases ≥ 5 mm (ii) 3 or more lymph node metastases < 5 mm  IIIC: Positive node(s) with extracapsular spread
    • 38. Stage IV: tumor invades other regional (2/3 upper urethra or vagina), or distant structures.  IVA: cancer invades any of the following: (i) upper urethral and/or vaginal mucosa, bladder mucosa, rectal mucosa, or fixed to pelvic bone. (ii) fixed or ulcerated inguino-femoral lymph nodes  IVB: any distant metastasis including pelvic lymph nodes
    • 39. Principles of treatment  Treatment should be individualized for each patient.  A full pre-operative work-up, including colposcopy of cervix, vagina and vulva, should be performed to assess the extent of subclinical disease.  Preinvasive disease should be removed with the primary lesion, if feasible.
    • 40. Principles of treatment  Surgery attempts to  1) Stage (i.e., assess the extent of disease and hence the prognosis).  2) Debulk a) Primary Tumor b) Lymph Nodes  Conservative surgery is preferred over radical surgery as long as prognosis is not adversely affected.
    • 41. Principles of treatment  Vulvar cancers spread by embolozation, not permeation so tissue between tumor and LNs need not be ressected (i.e., en bloc).  When recurrence occurs locally, it reflects the behaviour of the disease, not inadequate ressection.
    • 42. Principles of treatment  Positive margin need re-excision  Positive groin node two or more microscopic , one or more macroscopic, any extra-capsular spread need adjuvant radiation.  Elimination of routine pelvic lymphadenectomy in case of positive groin node i.e. pelvic radiation( GOG).  Adjuvant radiation required to the vulva in locally advanced disease after excision.  Chemotherapy may be useful in the treatment of locally advanced disease( to avoid urostomy or if there is bone involvement) /distant metastases and recurrent disease in groin.
    • 43. Requirment for unilateral LND  UNIFOCAL  Lateral more than 1 cm from the mid line  Not located in the ant. Portion of the labia minora  No palapable groin node in both side  No l. node mets found at the time of the unilat LND
    • 44. Treatment
    • 45. Treatment Surgery LN Radiation Chemotherapy IA(T1) 1 mm invasion Ipsilateral/ Bilateral Groin - - II(T2) III (T3 – early) ¯ OR Radical Vulvectomy Bilateral Groin + - III (T3 – late) IV (T4) Rad. Vulvectomy/ Exenteration N2/ N3 Groin ± Bilateral Groin & Pelvic Preop ? Recurrence Rexcison + ?
    • 46. Treatment Radical local excision: • A wide (1-2 cm margins) and deep (to the inferior fascia of the urogenital diaphragm) excision of the primary tumor • Closure: primary two layers Surgery LN Radiation Chemotherapy IA(T1) 1 mm invasion Ipsilateral/ Bilateral Groin - - T2 T3 – early ¯ OR Radical Vulvectomy Bilateral Groin + - T3 – late T4 Rad. Vulvectomy/ Exenteration N2/ N3 Groin ± Bilateral Groin & Pelvic Preop + Recurrence Rexcison + + Radical local excision: Radical Vulvectomy • •
    • 48. Treatment Surgery LN Radiation Chemotherapy IA Radical local Excison - - - IB Ipsilateral/ Bilateral Groin - - II(T2) III (T3 – early) ¯ OR Radical Vulvectomy Bilateral Groin + - T3 – late T4 Rad. Vulvectomy/ Exenteration N2/ N3 Groin ± Bilateral Groin & Pelvic Preop ? Recurrence Rexcison + ? Radical Vulvectomy +/- myo-cutaneous flab •
    • 49. Surgical Challenges
    • 50. Treatment Surgery LN Radiation Chemotherapy IA Radical local Excison - - - IB Ipsilateral/ Bilateral Groin - - II(T2) III (T3 – early) ¯ OR Radical Vulvectomy Bilateral Groin + - III (T3 – late) IV (T4) Rad. Vulvectomy/ Exenteration N2/ N3 Groin ± Bilateral Groin & Pelvic Preop Cis or 5FU Recurrence Rexcison ? ? Exenteration: • En bloc dissection from: • the cardinal ligaments laterally • the broad ligaments of the rectum posteriorly • the supralevator attachments of the bladder, urethra & vagina anteriorly • the perineum around vagina & anus caudally • Reconstruct vagina with gracilis myocutaneous flap • 10% operative mortality
    • 51. •Surface epithelium • only possible with laser • Epidermis & papillary dermis • Condylomata • Epidermis & part of reticular dermis • VIN • To fascia • Malignancy Principles of excision 4th plane
    • 52. 1. Acetic Acid 2. Colposcopy 3. Outline incision Principles of excision
    • 53. 4. Select appropriate depth Principles of excision
    • 54. 5. Mobilize adjacent tissues • Vagina • Perineum Principles of excision
    • 55. 6. Primary Closure/ Graft 7. Post operative • Analgesia • Sitz baths • Stool softner • Bedrest • DVT prophylaxis • +/- Drains Principles of excision
    • 56. Radical Vulvectomy ( Basset’s operation) Antoine Basset (1882-1951) Paris First to publish 147 cases of vulval cancer which he called cancer of the clitoris Rev Chir 1912 ‘’ The evolution of the disease appears to be rather rapid without surgical treatment, at least after the tumour is ulcerated, and the prognosis is then always fatal. It is still very somber after the mutilating operation, because of great frequency of local, and above all nodal, recurrence. But this seems amenable to improvement by early and systemic extirpation including all the lymphatics and nodes that drain the clitoris ‘’
    • 57. Treatment Surgery LN Radiation Chemotherapy IA Radical local Excison - - - IB Ipsilateral/ Bilateral Groin - - T2 T3 – early ¯ OR Radical Vulvectomy Bilateral Groin + - T3 – late T4 Rad. Vulvectomy/ Exenteration N2/ N3 Groin ± Bilateral Groin & Pelvic Preop ? Recurrence Rexcison + ? Groin (Inguinal and Femoral) LN Dissection: • Linear incision medial 4/5ths between ASIS and pubic tubercle • Dissect between fascia lata and superficial fascia, preserving tissue above • Tie off saphenous vein • Inguinal: above fascia lata, 2cm above inguinal ligament, medially by adductor longus, laterally by sartorius • Femoral: Below fascial lata, medial to femoral vein at opening of the femoral ring
    • 58. Inguinal LN Dissection
    • 59. Inguinal LN Dissection  High perioperative morbidity:  Requires 3-4 days of bed rest, wound breakdown 50%, lymphocele, lymphedema, infection, bleeding, DVT • Can some low-risk women avoid full LN dissection? Sentinel Node Biopsy
    • 60. Sentinel Node Biopsy • Used in breast CA and melanoma • Two methods: – Radiolabelled human albumin and gamma-detecting probe Possible 91-100% NPV: 100% – Isosulfan blue dye Possible 56-75% NPV: 96-100%
    • 61. Key Points  VIN is a condition of increasing importance with multiple methods of treatment  At least two possible etiologies are considered for vulvar cancer. One is related to infection with oncogenic HPV , other is related to maturation disorders  Management must address local control and regional ( nodal ) disease  The evolution of management has been driven by desire to reduce morbidity whilst maintaining disease control  Vulvar cancer is a challenging disease to treat. Its rarity has mindered attempts to improve management through clinical trials
    • 62. Thank You!
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